Claim Form

Claimant Information

Please provide contact information below. You must notify the Sewttlement Administrator if your contact information changes after you submit this Claim Form.

First Name

Last Name

Address 1

Address 2

City

State

Zip Code

Phone

Email

Claim Information

Please provide the mailing address which you provided to Joyous, PBC between October 5, 2023 and January 2, 2025.

Address 1

Address 2

City

State

Zip Code

Payment Election

Please select one of the following payment options.

IMPORTANT NOTES:

For E-Mastercard, PayPal, Venmo, and Zelle payments, if there are any discrepancies, if the account is no longer active, or if the Settlement Administrator deems that payment cannot or should not be made based on the provided information, the Claims Administrator will either contact you for clarification or be authorized to default to a Check payment.
If domestic or international payment limits apply to your payment, you may receive more than one transmission or you may default to a Check payment.
Venmo and Zelle payments cannot be made to accounts outside of the United States.
Payments by Check will be made out to the Name on this Claim Form and mailed to the address on this Claim Form.

Attestation & Signature

By signing below and submitting this Claim Form, I declare under penalty of perjury that between October 5, 2023 through January 2, 2025 I reported to Defendant Joyous PBC that I: (1) located Defendant Joyous PBC by a method other than a web advertisement; and (2) booked an appointment to use the services provided by Defendant Joyous PBC, completed a screening questionnaire related to the booking process and subsequently received on or more web-directed advertisements relating to ketamine treatments.

Signature

Date